Women’s Health & Pain

Recognition of the important biological differences between men and women when it comes to pain processing is key to providing optimum care to women with both sub-acute and chronic musculoskeletal and pain conditions. Besides the now well- recognized differences in pain modulation between the sexes, women’s bodies also tend to undergo greater changes over the course of a lifetime than do men’s.

There are likely to be multiple reasons for this but hormonal differences between the sexes may be important mediating factors and hormone imbalance issues should be sought in women presenting with pain problems. Pregnancy, labor and delivery, hormonal fluctuations of the menstrual cycle, and the decrease in gonadal hormones that accompany menopause may all affect the musculoskeletal and neurological systems in varied and complex ways that may result in painful conditions. The precise mechanisms by which these changes occur remain under investigation.

Nevertheless, pain programs in Women’s Health at Pain Ease is designed to address the needs of women with a variety of health issues including, but not limited to, pregnancy and postpartum-related musculoskeletal problems, pelvic pain and pelvic floor muscle dysfunction, fibromyalgia and myofascial pain, osteoporosis and its complications, and general musculoskeletal health and fitness.

In addition, our pain management programs recognize the effects of the sex hormones on pain processing and attempt to address underlying issues of hormone imbalance our female patients fill out a menstrual history and to enquire about various hormone-related symptoms on the initial patient questionnaire. Those responding positively may be asked in more detail about their hormonal status. This is also a good way to uncover bothersome symptoms that a patient may not report of their own accord such as urinary incontinence or pelvic pain. Such symptoms may respond positively to various integrative treatment strategies.

Pregnancy and Postpartum-Related Pain

Painful conditions of the musculoskeletal and neurological systems and back and pelvic pain, in particular, occur commonly both during and after pregnancy. Retrospective and prospective studies estimate that somewhere between 50–60% of pregnant women experience new onset back pain during pregnancy with at least one third of these experiencing disabling symptoms (. However, despite the high frequency of such problems, recognition of them as treatable conditions remains low, and medical care of the pregnant woman, except in extreme life and health-threatening situations, tends to focus on the health of the fetus to an extreme degree, likely in part because of the litigious environment in which medicine is currently practiced.

In addition, the postpartum time period has been recognized as one in which women experience multiple health problems, including fatigue, incontinence, back pain, headache and depression, however, these issues are frequently underestimated or overlooked by healthcare professionals . In general, the traditional response to such complaints by pregnant and postpartum women has been that pain is a normal and expected part of these time periods and that these issues will spontaneously resolve without treatment.

Women who experience musculoskeletal pain during pregnancy are frequently told to rest and await resolution of their symptoms after delivery. This gives the impression that the only treatment available for pain during pregnancy is rest. However, rest is an unacceptable treatment for back and other pain conditions occurring during pregnancy for several reasons. Rest is no longer considered an appropriate treatment for low back pain (LBP), in general; and, in fact, greater than three days of bed rest for acute LBP has been shown to be detrimental to recovery.

If that is the case, then certainly several months of rest could impede the recovery process by contributing to significant deconditioning and functional limitations. Secondly, many women are not able to rest during pregnancy, as they may be working full time, caring for other children, and are simply unable to put their lives on hold for nine months. It is, therefore, essential that healthcare providers find ways of helping them in order to limit their pain and preserve their functional integrity. In addition, there are several safe, though not rigorously studied, treatments available for back and pelvic pain of pregnancy.

Pelvic Pain and Pelvic Floor Muscle Dysfunction

Pelvic pain and pelvic floor muscle dysfunction are common problems among women of childbearing age and these issues may persist without appropriate treatment. In addition, many women during the postmenopausal years may suffer from urinary incontinence or painful symptoms in the pelvic region due to the extensive hormonal changes occurring during that time period. Women with pelvic pain and disorders of the pelvic floor may benefit from treatment in an interdisciplinary setting where they are offered conservative therapeutic options that may replace or act in an adjunctive manner to surgical interventions and/or pharmacological modalities when outcomes are sub-optimal or risks are unacceptable. The complex and sensitive nature of pelvic problems demands compassionate and knowledgeable women’s health providers who are comfortable with the multi-specialty collaboration that is often required in their management. Pain management specialists in women’s health should build reliable referral sources within the fields of gynecology, urology, gastroenterology, endocrinology, and psychology/psychiatry, as well as within the disciplines of physical and occupational therapy and with alternative health providers who are experienced in dealing with women’s health issues.

Osteoporosis

Osteoporosis is the most common metabolic bone disease, failure to maintain adequate bone mass during the middle decades, and then accelerated bone loss at menopause all contribute to the disease. Genetic, hormonal, environmental, and nutritional factors cause the rate of bone degradation (resorption) to exceed that of bone formation, resulting in reduced bone mineral density.

Osteoporosis has many risk factors, including tobacco use, sedentary lifestyle, low body weight, and female gender. Female gender predisposes to osteoporosis due to lower baseline mean peak bone mass and accelerated bone loss after menopause . After age 50, a hip or vertebral fracture is three times more likely for a woman than for a man (16 to 18 percent versus 5 to 6 percent) and a Colles fracture is six times more likely for a woman (16 percent versus 2.5 percent)

Bone loss begins in early menopause, most significantly due to estrogen deficiency. After menopause, the ovary secretes little or no estrogen. Estrogen deficiency changes the balance between osteoblastic cells (involved in bone building) and osteoclastic cells (involved in bone destruction) because osteoblastic cell function requires estrogen.

Prevention and treatment of osteoporosis consist of both non-drug and drug therapies. An optimal diet for treatment (or prevention) of osteoporosis includes an adequate calorie, calcium, and vitamin D intake .Also, Isoflavones phytoestrogens(Soybeans and soy foods are the most significant sources of isoflavones. Chickpeas and other legumes, as well as clover and bluegrass, are also sources of isoflavones) have garnered attention as alternative treatments for osteoporosis. Exercise is an excellent non pharmacologic therapy for osteoporosis. Bone responds to mechanical stress by increasing its mass and strength, either by the direct impact from the weight-bearing activity or by the action of attached muscle.To be beneficial, exercise does not have to be done by the young. Older postmenopausal women and even the frail elderly can tolerate and potentially show improvements in muscle strength and BMD in response to strength training and resistive exercise programs

Knee Pain in Women

Given the higher rates of multiple knee problems in women, hormonal differences between the sexes have been implicated as a possible causative factor. The sex hormones may exert effects on various aspects of knee problems that may include differences in pain sensitivity as discussed earlier in this chapter, neuromuscular factors such as reaction time and coordination of muscle contraction, and biomechanical factors like ligamentous laxity.

Some of the most common chronic painful conditions of the knee occur more commonly in women than in men. These conditions include knee osteoarthritis (OA) in older women , patellofemoral pain syndrome (PFPS), and sports-related knee injuries such as tears of the anterior cruciate ligament (ACL) . Women also do more poorly than men in long-term follow-up studies after menisectomy surgery and may also have a greater risk than men of developing symptoms of complex regional pain syndrome (CRPS) following menisectomy,although there is little published on this topic. The reasons behind these sex differences in knee pain remain incompletely understood and are likely to be multifactorial.

Women may not respond as favorably as men to surgical treatments of knee problems and when possible conservative measures should be employed aggressively prior to surgical consideration. Among the integrative treatments that may benefit women with knee pain are acupuncture, trigger point injections, alternative forms of exercise such as Yoga and Tai Chi, osteopathic manipulative techniques, nutritional supplementation, weight loss if necessary, and neuromuscular athletic training programs for the athlete. Women presenting with knee pain would benefit from evaluation and treatment at Pain Ease Clinic.

Upper Extremity Pain in Women

Women are at increased risk as compared to men of developing musculoskeletal pain of the upper extremities. The reasons for this are, again, multifactorial. An under- standing of the myriad of upper extremity conditions that women may be affected by, the underlying reasons for this, and the recommended treatments is essential to the women’s musculoskeletal health and pain medicine provider.

After age 10–12 years there are significant differences in physical performance between males and females. Females reach physiological and skeletal maturity and peak height velocity earlier than males. Women also have more body fat and less lean body mass than males, a difference that can be attributed to increased estrogens in the female and increased androgens in the male . Females have less upper body strength, which even with training remains 30% to 50% less than that of males. Lower extremity strength is much closer in parity . Despite these differences women show the same physiological training changes as males and experience significant increases in strength, power, and muscular endurance.

Physiologic gender differences predispose women to upper extremity musculoskeletal disorders. Women have shorter upper extremities, an increased valgus-carrying angle, decreased upper extremity strength, and increased ligamentous laxity compared with males The shoulder, which is the body’s most mobile joint, is particularly vulnerable. In younger females, increased joint laxity and decreased strength can cause shoulder problems. The vicious cycle of physiological joint insta-bility, rotator cuff weakness, pain, posterior capsule tightness, and further imbalance results in persistent pain and dysfunction in overhead activities. Care should be taken to address scapular dysfunction. A specific diagnosis of the cause of the pain should be made. Restoration of normal range of motion and strength with proper sport biome-chanics should be the goal.

Shoulder instability is a problem for young women. However, as she ages, a woman because susceptible to adhesive capsulitis, otherwise known as ‘’frozen shoulder.’

Wrist, hand, and finger pain are also common in women. Women are often affected by painful osteoarthritis of the fingers and hands for reasons that remain unclear.Finger discomfort, particularly numbness, may also be caused by carpal tunnel syndrome (CTS) ,Stenosing tenosynovitis, or “trigger finger,” is a condition involving the flexor tendon of the thumb or individual finger causing catching or “locking” of the digit in flexion. After trigger finger, De Quervain tenosynovitis is the second most common stenosing tenosynovitis of the upper extremity. It involves the first dorsal compartment of the wrist, which includes the abductor pollicis longus (APL) and extensor pollicis brevis (EPB).

As women, especially those involved in various athletic activities and repetitive tasks, are at high risk of developing upper extremity pain or injury, our healthcare providers have a high degree of comfort with diagnosing and treating these disorders.

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